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Maintain records that are up to date, complete, accurate and legible

Qualification: Level 3 Diploma in Adult Care
Unit name: Handle information in care settings
Learning outcome: 2. Be able to implement good practice in handling information
Assessment criteria: 2.3 Maintain records that are up to date, complete, accurate and legible

The integrity of any information that you record should always be maintained. This means that all your documentation should be up-to-date, complete, accurate and legible.

Up-to-date information is important because it ensures that everyone is kept informed of any changes. Outdated information could result in co-workers performing care tasks that are no longer necessary or not performing essential care tasks.

Records should also be complete – if there are any missing pieces, it can mean that individuals are not getting the full pictures and not have all the information they need to carry out their role or make informed decisions.

Similarly, records should be accurate and factual. Objectivity is important because personal views and opinions can be open to interpretation and will vary between individuals.

Finally, all written records should be legible. If nobody is able to read what you have written, they will not be able to comprehend the required information.